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Deep brain stimulation of the "medial forebrain bundle": a strategy to modulate the reward system and manage treatment-resistant depression. Mol Psychiatry 2022; 27:574-592. [PMID: 33903731 DOI: 10.1038/s41380-021-01100-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 02/02/2023]
Abstract
The medial forebrain bundle-a white matter pathway projecting from the ventral tegmental area-is a structure that has been under a lot of scrutinies recently due to its implications in the modulation of certain affective disorders such as major depression. In the following, we will discuss major depression in the context of being a disorder dependent on multiple relevant networks, the pathological performance of which is responsible for the manifestation of various symptoms of the disease which extend into emotional, motivational, physiological, and also cognitive domains of daily living. We will focus on the reward system, an evolutionarily conserved pathway whose underperformance leads to anhedonia and lack of motivation, which are key traits in depression. In the field of deep brain stimulation (DBS), different "hypothesis-driven" targets have been chosen as the subject of clinical trials on efficacy in the treatment-resistant depressed patient. The "medial forebrain bundle" is one such target for DBS, and has had remarkably rapid success in alleviating depressive symptoms, improving anhedonia and motivation. We will review what we have learned from pre-clinical animal studies on defining this white matter tract, its connectivity, and the complex molecular (i.e., neurotransmitter) mechanisms by which its modulation exerts its effects. Imaging studies in the form of tractographic depictions have elucidated its presence in the human brain. Such has led to ongoing clinical trials of DBS targeting this pathway to assess efficacy, which is promising yet still lack in sufficient numbers. Ultimately, one must confirm the mechanism of action and validate proof of antidepressant effect in order to have such treatment become mainstream, to promote widespread improvement in the quality of life of suffering patients.
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The evidence base for psychotropic drugs approved by the European Medicines Agency: a meta-assessment of all European Public Assessment Reports. Epidemiol Psychiatr Sci 2020; 29:e120. [PMID: 32336312 PMCID: PMC7214735 DOI: 10.1017/s2045796020000359] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS To systematically assess the level of evidence for psychotropic drugs approved by the European Medicines Agency (EMA). METHODS Cross-sectional analysis of all European Public Assessment Reports (EPARs) and meta-analyses of the many studies reported in these EPARs. Eligible EPARs were identified from the EMA's website and individual study reports were requested from the Agency when necessary. All marketing authorisation applications (defined by the drug, the route of administration and given indications) for psychotropic medications for adults (including drugs used in psychiatry and addictology) were considered. EPARs solely based on bioequivalence studies were excluded. Our primary outcome measure was the presence of robust evidence of comparative effectiveness, defined as at least two 'positive' superiority studies against an active comparator. Various other features of the approvals were assessed, such as evidence of non-inferiority v. active comparator and superiority v. placebo. For studies with available data, effect sizes were computed and pooled using a random effect meta-analysis for each dose of each drug in each indication. RESULTS Twenty-seven marketing authorisations were identified. For one, comparative effectiveness was explicitly considered as not needed in the EPAR. Of those remaining, 21/26 (81%) did not provide any evidence of superiority against an active comparator, 2/26 (8%) were based on at least two trials showing superiority against active comparator and three (11%) were based on one positive trial; 1/26 provided evidence for two positive non-inferiority analyses v. active comparator and seven (26%) provided evidence for one. In total, 20/27 (74%) evaluations reported evidence of superiority v. placebo with two or more trials. Among the meta-analyses of initiation studies against active comparator (57 available comparisons), the median effect size was 0.051 (range -0.503; 0.318). Twenty approved evaluations (74%) reported evidence of superiority v. placebo on the basis of two or more initiation trials and seven based on a single trial. Among meta-analyses of initiation studies against placebo (125 available comparisons), the median effect size was -0.283 (range -0.820; 0.091). Importantly, among the 89 study reports requested on the EMA website, only 19 were made available 1 year after our requests. CONCLUSIONS The evidence for psychiatric drug approved by the EMA was in general poor. Small to modest effects v. placebo were considered sufficient in indications where an earlier drug exists. Data retrieval was incomplete after 1 year despite EMA's commitment to transparency. Improvements are needed.
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Coenen VA, Bewernick BH, Kayser S, Kilian H, Boström J, Greschus S, Hurlemann R, Klein ME, Spanier S, Sajonz B, Urbach H, Schlaepfer TE. Superolateral medial forebrain bundle deep brain stimulation in major depression: a gateway trial. Neuropsychopharmacology 2019; 44:1224-1232. [PMID: 30867553 PMCID: PMC6785007 DOI: 10.1038/s41386-019-0369-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/04/2019] [Accepted: 03/03/2019] [Indexed: 12/13/2022]
Abstract
Short- and long-term antidepressant effects of deep brain stimulation (DBS) in treatment-resistant depression (TRD) have been demonstrated for several brain targets in open-label studies. For two stimulation targets, pivotal randomized trials have been conducted; both failed a futility analysis. We assessed efficacy and safety of DBS of the supero-lateral branch of the medial forebrain bundle (slMFB) in a small Phase I clinical study with a randomized-controlled onset of stimulation in order to obtain data for the planning of a large RCT. Sixteen patients suffering from TRD received DBS of the slMFB and were randomized to sham or real stimulation for the duration of 2 months after implantation. Primary outcome measure was mean reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) during 12 months of DBS (timeline analysis). Secondary outcomes were the difference in several clinical measures between sham and real stimulation at 8 weeks and during stimulation phases. MADRS ratings decreased significantly from 29.6 (SD +/- 4) at baseline to 12.9 (SD +/- 9) during 12 months of DBS (mean MADRS, n = 16). All patients reached the response criterion, most patients (n = 10) responded within a week; 50% of patients were classified as remitters after 1 year of stimulation. The most frequent side effect was transient strabismus. Both groups (active/sham) demonstrated an antidepressant micro-lesioning effect but patients had an additional antidepressant effect after initiation of stimulation. Both rapid onset and stability of the antidepressant effects of slMFB-DBS were demonstrated as in our previous pilot study. Given recent experiences from pivotal trials in DBS for MDD, we believe that slow, careful, and adaptive study development is germane. After our exploratory study and a large-scale study, we conducted this gateway trial in order to better inform planning of the latter. Important aspects for the planning of RCTs in the field of DBS for severe and chronic diseases are discussed including meaningful phases of intra-individual and between-group comparisons and timeline instead of single endpoint analyses.
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Affiliation(s)
- Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Bettina H Bewernick
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
- Department of Interventional Biological Psychiatry, University Hospital Freiburg, Freiburg, Germany
| | - Sarah Kayser
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Hannah Kilian
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Division of Neuroradiology, Department of Radiology, University of Bonn, Bonn, Germany
| | - Jan Boström
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Susanne Greschus
- Division of Neuroradiology, Department of Radiology, University of Bonn, Bonn, Germany
| | - René Hurlemann
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Margaretha Eva Klein
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Susanne Spanier
- Department of Interventional Biological Psychiatry, University Hospital Freiburg, Freiburg, Germany
| | - Bastian Sajonz
- Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Horst Urbach
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Division of Neuroradiology, Department of Radiology, University of Bonn, Bonn, Germany
- Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
| | - Thomas E Schlaepfer
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany.
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
- Department of Interventional Biological Psychiatry, University Hospital Freiburg, Freiburg, Germany.
- Departments of Psychiatry and Mental Health, The Johns Hopkins University, Baltimore, MD, USA.
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Safer DJ, Zito JM. Short- and Long-Term Antidepressant Clinical Trials for Major Depressive Disorder in Youth: Findings and Concerns. Front Psychiatry 2019; 10:705. [PMID: 31681028 PMCID: PMC6797591 DOI: 10.3389/fpsyt.2019.00705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/02/2019] [Indexed: 01/20/2023] Open
Abstract
The diagnosis of major depressive disorder (MDD) in U.S. youth is increasing as is the rate of antidepressant medication (ADM) treatment for the disorder. Fluoxetine and escitalopram are FDA approved for the short term and maintenance treatment of MDD in youth. Placebo-controlled short-term ADM trials represent the basis for Food and Drug Administration (FDA) approval. Meta-analyses in 2007 and 2016 revealed that short-term ADM treatment of youth diagnosed with MDD resulted in no meaningful benefit for children and only marginal benefit for adolescents. Placebo substitution trials of ADM short-term responders represent the basis for FDA approval of ADM maintenance treatment. These ADM placebo substitution maintenance trials for youth with MDD are characterized by high dropout rates, a rapid withdrawal that often can follow the switch to placebo, and relapse rates that are not dissimilar from those in the natural course of the disorder. Without the evidence from problematic ADM placebo substitution trials, there is no acceptable support for the inclusion of ADM in maintenance treatment for MDD in youth.
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Affiliation(s)
- Daniel J Safer
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julie Magno Zito
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, United States.,Department of Psychiatry, University of Maryland, Baltimore, Baltimore, MD, United States
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Delmas H, Batail JM, Falissard B, Robert G, Rangé M, Brousse S, Soulabaille J, Drapier D, Naudet F. A randomised cross-over study assessing the "blue pyjama syndrome" in major depressive episode. Sci Rep 2017; 7:2629. [PMID: 28572626 PMCID: PMC5453951 DOI: 10.1038/s41598-017-02411-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/19/2017] [Indexed: 11/12/2022] Open
Abstract
This paper introduces a “blue pyjama syndrome” (whereby wearing hospital pyjamas results in an exaggerated impression of severity). We performed a 5-day, prospective, randomized, cross-over study in a French mood disorder unit for inpatients. At Day 1 (D1) and Day 5 (D5), two 5-minute video interviews were recorded with patients in pyjamas or in day clothes (the sequence was randomly allocated). Psychiatrists unaware of the study objective assessed the videos and scored their clinical global impressions (CGI, with scores ranging from 1 to 7). Of 30 participants with major depressive episode selected for inclusion, 26 participants (69% women) provided useable data for an evaluation by 10 psychiatrists. Pyjamas significantly increased the psychiatrists’ CGI ratings of disease severity by 0·65 [0·27; 1·02] points. The psychiatrists’ global impressions also rated patients as significantly less severe at D5 in comparison with D1 by −0·66 [−1·03; −0·29] points. The “blue pyjama syndrome” is in the same order of magnitude as the difference observed after a week of hospitalisation. This potentially calls into question the reliability and validity of observer ratings of depression.
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Affiliation(s)
- Hélèna Delmas
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France
| | - Jean-Marie Batail
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France.,EA 4712 Behavior and Basal Ganglia, CHU Rennes, Rennes 1 University, Rennes, France
| | - Bruno Falissard
- CESP, Univ.Paris-Sud, Université Paris-Saclay, UVSQ, INSERM U1178, Paris, France
| | - Gabriel Robert
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France.,EA 4712 Behavior and Basal Ganglia, CHU Rennes, Rennes 1 University, Rennes, France
| | - Maxence Rangé
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France.,EA 4712 Behavior and Basal Ganglia, CHU Rennes, Rennes 1 University, Rennes, France
| | - Stéphane Brousse
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France
| | - Jacques Soulabaille
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France
| | - Dominique Drapier
- Academic Psychiatry Department, Centre Hospitalier Guillaume Régnier, Rennes, France.,EA 4712 Behavior and Basal Ganglia, CHU Rennes, Rennes 1 University, Rennes, France
| | - Florian Naudet
- INSERM CIC-P 1414, Clinical Investigation Center, CHU Rennes, Rennes 1 University, Rennes, France. .,Meta-Research Innovation Center at Stanford (METRICS), Stanford School of Medicine, Palo Alto, CA, 94304, USA.
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Berger D. Double-Blinding and Bias in Medication and Cognitive-Behavioral Therapy Trials for Major Depressive Disorder. F1000Res 2015; 4:638. [PMID: 26870318 DOI: 10.12688/f1000research.6953.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2015] [Indexed: 11/20/2022] Open
Abstract
While double-blinding is a crucial aspect of study design in an interventional clinical trial of medication for a disorder with subjective endpoints such as major depressive disorder, psychotherapy clinical trials, particularly cognitive-behavioral therapy trials, cannot be double-blinded. This paper highlights the evidence-based medicine problem of double-blinding in the outcome research of a psychotherapy and opines that psychotherapy clinical trials should be called, "partially-controlled clinical data" because they are not double-blinded. The implications for practice are, 1. For practitioners to be clear with patients the level of rigor to which interventions have been studied, 2. For authors of psychotherapy outcome studies to be clear that the problem in the inability to blind a psychotherapy trial severely restricts the validity of any conclusions that can be drawn, and 3. To petition National Health Insurance plans to use caution in approving interventions studied without double-blinded confirmatory trials as they may lead patients to avoid other treatments shown to be effective in double-blinded trials.
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Berger D. Double-Blinding and Bias in Medication and Cognitive-Behavioral Therapy Trials for Major Depressive Disorder. F1000Res 2015; 4:638. [PMID: 26870318 PMCID: PMC4732552 DOI: 10.12688/f1000research.6953.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 11/20/2022] Open
Abstract
While double-blinding is a crucial aspect of study design in an interventional clinical trial of medication for a disorder with subjective endpoints such as major depressive disorder, psychotherapy clinical trials, particularly cognitive-behavioral therapy trials, cannot be double-blinded. This paper highlights the evidence-based medicine problem of double-blinding in the outcome research of a psychotherapy and opines that psychotherapy clinical trials should be called, “partially-controlled clinical data” because they are not double-blinded. The implications for practice are, 1. For practitioners to be clear with patients the level of rigor to which interventions have been studied, 2. For authors of psychotherapy outcome studies to be clear that the problem in the inability to blind a psychotherapy trial severely restricts the validity of any conclusions that can be drawn, and 3. To petition National Health Insurance plans to use caution in approving interventions studied without double-blinded confirmatory trials as they may lead patients to avoid other treatments shown to be effective in double-blinded trials.
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Naudet F, Boussageon R, Palpacuer C, Gallet L, Reymann JM, Falissard B. Understanding the Antidepressant Debate in the Treatment of Major Depressive Disorder. Therapie 2015; 70:321-7. [PMID: 25679188 DOI: 10.2515/therapie/2014228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 11/20/2014] [Indexed: 11/20/2022]
Abstract
There is a long-standing polemic concerning the usefulness of antidepressants in the treatment of major depressive disorder. In this paper, we propose to highlight some aspects of this controversy by exploring the mutual influence of psychopharmacology and trial methodologies. Indeed, antidepressant efficacy, if not proved, was accepted before antidepressant randomised controlled trials (RCTs) were run. While RCTs became a gold standard to meet the requirements of the regulatory bodies, methodological tools were required to measure outcomes and to test whether antidepressants provide statistically significant benefits as compared with a placebo. All these methodological options have nonetheless introduced fuzziness in our interpretation of study results, in terms of clinical meaningfulness and in terms of transposability to a real life settings. Additionally, selective publication raises concerns about the published literature, and results in many paradoxes. Instead of providing easy answers, the application of the RCT paradigm in MDD raises numerous questions. This is probably in the nature of all scientific studies, but it can be in contradiction with clinicians' expectations, who want to be sure that the treatment will (or will not) work for their individual patients.
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Affiliation(s)
- Florian Naudet
- INSERM U669, Paris, France - Centre d'Investigation Clinique CIC-P INSERM 1414, Hôpital de Pontchaillou, Centre Hospitalier Universitaire de Rennes & Université de Rennes 1, Rennes, France - Centre Hospitalier Guillaume Régnier, Service Hospitalo-Universitaire de psychiatrie, Rennes, France
| | - Rémy Boussageon
- Faculté de Médecine de Poitiers, Département de Médecine Générale, Poitiers, France
| | - Clément Palpacuer
- Centre d'Investigation Clinique CIC-P INSERM 1414, Hôpital de Pontchaillou, Centre Hospitalier Universitaire de Rennes & Université de Rennes 1, Rennes, France
| | - Laurent Gallet
- Centre Hospitalier Guillaume Régnier, Service Hospitalo-Universitaire de psychiatrie, Rennes, France
| | - Jean-Michel Reymann
- Centre d'Investigation Clinique CIC-P INSERM 1414, Hôpital de Pontchaillou, Centre Hospitalier Universitaire de Rennes & Université de Rennes 1, Rennes, France - Laboratoire de Pharmacologie Expérimentale et Clinique, Faculté de Médecine de Rennes, Rennes, France
| | - Bruno Falissard
- INSERM U669, Paris, France - Université Paris-Sud et Université Paris Descartes, UMR-S0669, Paris, France - AP-HP, Hôpital Paul Brousse, Département de Santé Publique, Villejuif, France
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Affiliation(s)
- Florian Naudet
- INSERM U669, Université Paris-Sud and Université Paris Descartes, UMR-S0669, Paris Cedex 14, France.
| | - Bruno Falissard
- INSERM U669, Université Paris-Sud and Université Paris Descartes, UMR-S0669, Paris Cedex 14, France
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